State officials investigating a June 2008 surgical fire at Abbott Northwestern Hospital in Minneapolis have faulted the facility for violating two federal health codes that could have prevented the incident.

According to the St. Paul Pioneer Press, the state’s investigative report finds that the OR in which the procedure (a pacemaker replacement) was performed did not have an ether shield installed to reduce the risk of surgical fire. In addition, the surgeon who performed the case admitted that he did not always put the cautery gun in a protective holster when it wasn’t in use. The fire, which ignited over the patient while the surgeon was using the cautery gun, resulted in second-degree burns on the patient’s nose and lips and a third-degree burn on her shoulder.

The hospital reported the incident last year and has since halted pacemaker replacements in the improperly equipped OR until an ether shield can be installed and re-educated staff on surgical fire prevention.

—Irene Tsikitas